Over the last two decades, outcomes in multiple myeloma have improved dramatically with the introduction of high-dose melphalan and autologous stem cell transplantation, immunomodulatory agents (thalido-mide, lenalidomide, pomalidomide), proteasome inhibitors (bortezomib, carfilzomib, ixazomib) and, more recently, monoclonal antibodies (daratumumab, elo-tuzumab). Clinical data from multiple randomized trials have demonstrated the benefits of these agents during the induction, consolidation, and maintenance phases of myeloma therapy. In their review, Branagan et al provide an excellent summary of these data and describe their approach to treating patients with myeloma. They advocate for the use of lenalidomide-bortezomib-dexamethasone (RVd) during induction and consolidation, first-line autologous stem-cell transplantation for eligible patients, and prolonged risk-adapted maintenance with either single-agent lenalidomide for standard-risk patients or continued RVd for high-risk patients with t(4;14), t(14;16), or del(17p). The treatment for patients who are not eligible for transplantation is largely similar with dose adjustments or doublet rather than triplet therapy as necessary for comorbidities or frailty. At our institution, we have used a similar approach for more than a decade with promising results. In 1,000 consecutive patients treated with RVd induction, we observed high response rates, a progression-free survival (PFS) of 65 months, and overall survival (OS) of more than 120 months. Long-term follow-up from ongoing prospective studies of RVd induction may provide corroborating evidence for the benefits of this regimen.
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